TRIO: UPWARD BOUND WICHITA PREP

WICHITA.EDU/UBWP

316-978-3019 OFFICE

Jaya.Escobar@wichita.edu

ATTENTION Mrs. Escobar-Bhattacharjee

TRIO: UPWARD BOUND EMPOWERMENT

WICHITA.EDU/EMPOWERMENT

316-978-6923 OFFICE

Shauntelle.Thompson@wichita.edu

ATTENTION Ms. Shauntelle Thompson

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WICHITA STATE UNIVERSITY

Office of Upward Bound Empowerment & Wichita Prep

Parents and Students

Thank you for your interest in the Wichita State University Upward Bound Empowerment or Upward Bound Wichita Prep Program! Parents and students, please take the time to read this information together. If you have any questions, I will be glad to schedule a time to meet with you. Upward Bound is a federal program, funded through the U.S. Department of Education. This Program is specifically designed to provide low-income and first generation (neither parent has a 4-yr. degree) students an opportunity to (1) improve their academic, social and personal skills and (2) fully prepare for a post-secondary education. Additionally, Upward Bound Empowerment is designed to be inclusive of students who are or have been in Foster Care. Our Programs provide cost-free services to students from the Wichita Public School District attending North, South, East, West, or Southeast High Schools. One Hundred Fifty-Seven freshmen, and sophomores are selected each year, along with a waiting list of 20. Once selected, students may continue in the Program until the summer following their graduation from high school. Applications are accepted year-round. The Upward Bound Programs have two components: Academic Year and Summer Residential. Each component is important and designed to motivate and encourage students to successfully complete high school and to attend a post-secondary institution. We encourage year-round participation so that students can truly benefit from the Program. Below is a description of each component: Academic Year Component (August - May)

• One-on-one tutoring in academic subjects. Students must attend tutoring session’s minimum of (2) hours weekly on the WSU campus.

• Career and college exploration, campus visits, ACT/SAT Test preparation, financial aid application assistance and personal guidance.

• Social and Cultural Programs.

• Bi-weekly Saturday Sessions that feature dynamic and motivating speakers from WSU and the community.

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Summer Residential Component (June & July)

• Intensive 4-8-week Collegiate Transition Program. The Program pays tuition for 3-6 hrs. of college courses at WSU. Students reside in university housing on the WSU campus. (Program graduates only)

• Intensive 5-week College Preparatory Program for 9th through 12th graders. Daily academic classes and tutorial assistance in basic and advanced courses. Students reside in university housing on the WSU campus.

• Social and Cultural Programs.

• Career and college exploration, campus visits and personal guidance. The Upward Bound/Wichita Prep Program is committed to assisting students improve their academic, social and personal skills. Thus, students must be committed and accept their participation seriously. To apply for admission, please send the following information:

• Completed Application

• H.S. Transcript

• Recommendation/Nomination Form (completed by a school official)

• Copy of Parent's Income Tax Return

• Copy of Insurance or Medical Card

Send to: ATTN: Rhonda Hicks Wichita State University Upward Bound/Wichita Prep Program 1845 N. Fairmount - Box 94 Wichita, KS 67260-0094

We enjoy the opportunity to assist students pursue their educational goals. Please feel free to contact our office at 978-3019, for further information or assistance.

Sincerely, Rhonda Hicks, Director

Upward Bound Empowerment or Upward Bound Wichita Prep Programs●

Wichita State University ●1845 Fairmount Wichita, Kansas 67260-100 or 67260-0094

UBWP Phone (316) 978-3019● UBE Phone (316) 978-5343 FAX (316) 978-3403

Wichita.edu/ube ● wichita.edu/ubwp The Upward Bound Wichita Prep program is 100% funded by the US Department of Education for 2019-2020 at $467,798.

The Upward Bound Empowerment program is 100% funded by the US Department of Education for 2019-2020 at $287,536

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Application for Admission-

Upward Bound –Empowerment or Upward Bound- Wichita Prep ●Wichita State University

Personal Information

First Name: MI: Last Name:

Social Security # __________________________________________ Age: _______________

Gender: Male Female Date of Birth: / / (MM/DD/YYYY)

Phone#1 ( ) - (Cell/Hm/Wk) Phone#2 ( ) - (Cell/Hm/Wk)

Address: Wichita, KS Zip________________

Email: Facebook: _____________________________

Ethnic Status: African American, Non-Hispanic American Indian or Alaskan Native

Hispanic White, Non-Hispanic

Asian, Pacific Islander, or Indian Sub-Continent

Are you a U.S. Citizen? Yes No If no, are you a permanent resident? Yes No

(If not a U.S. citizen, you must submit a copy of your permanent resident status.)

Do you have any special needs? Yes No

If yes, please explain:

Are you a participant in any school clubs or activities? Yes No

If yes, please explain:

Are you employed? Yes No If yes, how many hours do you work weekly?

Are you a participant in: Talent Search/Project Discovery? Yes No Gear Up? Yes No

Upward Bound/Math Science? Yes No Communication Upward Bound? Yes No

Academic Information

School: North South East West Southeast Grade: 8 9 10

School Counselor: When do you plan to graduate? 2021 2022 2023

What is your current GPA: What is your class Rank:___/___ How many credits have you earned

Have you failed any subjects? Yes No If yes, list the subjects:

Do you participate in any of the following Services at your school?

Math lab Reading/Writing Lab ESL Program Tutoring AVID Other__________

Are you having academic difficulty in any classes? Yes No

What are your present grades in the following subjects? Subject/Grade example Algebra II / B

English / Math / Science / .

History / Elective / Elective / .

Elective / Elective / Elective / .

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Family Information: Student lives with: Mother/ Father/ Both/ Guardian (please circle)

Mother

First Name: Last Name:

Phone#1 ( ) - (Cell/Hm/Wk) Phone#2 ( ) - (Cell/Hm/Wk)

Email: Address:

Father

First Name: Last Name:

Phone#1 ( ) - (Cell/Hm/Wk) Phone#2 ( ) - (Cell/Hm/Wk)

Email: Address:

Guardian – Grandparent/ Aunt/ Uncle /Foster/ Other

First Name: Last Name:

Phone#1 ( ) - (Cell/Hm/Wk) Phone#2 ( ) - (Cell/Hm/Wk)

Email: Address:

Emergency Contact (Person other than Parent)

First Name: Last Name:

Phone 1( ) - (Cell/Hm/Wk) Address:

Phone 2( ) - (Cell/Hm/Wk) Relationship:

Number of brothers and sisters living at home (or children supported by parents):

Brothers Sisters Others

Total number of family members at home (self-included):

Has either of the student’s parents received a four-year (bachelors) degree? Father Mother Neither

Has a family member participated in Upward Bound? Yes No If yes, who?

I understand the goals, objectives and requirements of the Upward Bound Program and agree to fulfill

them. I also understand that if I do not fulfill the required goals and objectives, I will be terminated from

the Program. I certify that all the information I have provided is valid and correct to the best of my

knowledge.

Student Signature Date

I understand the goals, objectives and requirements of the Upward Bound Program and agree to support

my child in fulfilling them. I also understand that if my son/daughter does not fulfill the required goals

and objectives, he/she will be terminated from the Program. I certify that all the information I have

provided is valid and correct to the best of my knowledge.

Parent Signature Date

Official Use Only: Eligibility Met Yes No If necessary verification provided Yes No

Notes:_________________________________________________________________________________________

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Family Financial Statement Upward Bound –Empowerment or Upward Bound- Wichita Prep ●Wichita State University

To be completed by parent/guardian

One of the criteria for admission is meeting the income guidelines established by the Department of

Education. Before we can determine your eligibility, please answer the following questions and attach a

copy of your income tax return.

THIS INFORMATION IS STRICTLY CONFIDENTIAL AND WILL BE MAINTAINED IN THE OFFICE IN

ACCORDANCE WITH THE GENERAL EDUCATION PROVISION ACT (which outlines privacy rights of

parents and students).

FAMILY INCOME:

1. Did you file an income tax return last year? Yes No

2. Gross family income (before taxes and other withholdings) for last year: $

3. Adjusted gross income: $ Taxable Income $__________________

4. Which of the following was the source of the above income? Check one or more.

Father's employment Occupation:

Mother's employment Occupation:

Government Assistance Rate per/month:

Social Security Rate per/month:

Other income:

Are you eligible for veteran’s benefits? Yes No If so, what kind?

5. How many dependents were claimed on your income tax form last year?

Total number of persons living in household (including self):

6. Foster child: List the child's monthly personal use income:

~I certify that all of the information on this form is valid and correct to the best of my knowledge.

~I understand that if I did not include my families’ most resent Income Tax Statement or my Social

Security Statement, I need to provide a written statement detailing my income to complete application.

Parent/Guardian Signature Date

Check the form(s) attached:

Income Tax Return Social Security Statement

Office use only

Income Household: Taxable income: Eligible

Foster child: Income Number of Dependents: _____ Income over allowed amount

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Insurance Provider Upward Bound –Empowerment or Upward Bound- Wichita Prep ●Wichita State University

To be completed by parent/guardian Is student covered by health insurance? Yes No

Student's Name: Member ID #___________________________

Insurance Company: Group # ___________________________

Parent/Guardian (s) Name(s): A__________________________ B______________________________

A Phone#1 ( ) - (Cell/Hm/Wk) Phone#2 ( ) - (Cell/Hm/Wk)

B Phone#1 ( ) - (Cell/Hm/Wk) Phone#2 ( ) - (Cell/Hm/Wk)

Emergency Contact Person: Relationship:

Phone#1 ( ) - (Cell/Hm/Wk) Phone#2 ( ) - (Cell/Hm/Wk)

Policy #: Effective. Date:

Other Card Info: _______________________________________________________________________

*Attach a copy of your child’s insurance card or if child is covered through KS Dept. Of Children and

Families, please attach a copy of your medical card to this form.

I/We have attached a copy of the student’s insurance or medical card Not Applicable

Medical Provider

I authorize the Upward Bound/Wichita Prep Program to provide emergency medical and dental services

for my child. I will not in any way hold Wichita State University or the Upward Bound/Wichita Prep

Program responsible for any treatment deemed necessary for medical/dental services.

Parent/Guardian Signature Date

Parental Release for Student Travel

I authorize the Upward Bound/Wichita Prep Program to provide transportation for my child

to program activities. I hereby release the Upward Bound/Wichita Prep Program from any responsibility

for any criminal act of malice, vandalism, theft, death or injury, and any other unlawful behavior during

his/her trips sponsored by the Upward Bound/Wichita Prep Program.

Parent/Guardian Signature Date

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Authorization for Release of Records Upward Bound –Empowerment or Upward Bound- Wichita Prep ●Wichita State University

Student’s Name: Social Security #:

Name of High School: Student ID#:

I hereby authorize USD 259 of Wichita, Kansas, or any USD we may move into, to furnish information

on my permanent records to the Wichita State University -Upward Bound program, until my completion

of the program.

Checked below is the information I authorize to be shared now or in the furture: (*= required)

Progress Reports

Attendance Reports

Behavior Reports

_______________ Medical Reports

State Assessment Test Results

X ACT/SAT Test Results *

Student VUE Login________________ Password________________

______X_________ Semester Transcripts *

______X_________ Final Transcript *

Please send this information to: Upward Bound Wichita Prep Upward Bound Empowerment

Wichita State University Wichita State University

1845 Fairmount 1845 Fairmount

Campus Box 94 Campus Box 100

Wichita, Kansas 67260-0094 Wichita, Kansas 67260-0100

Date:______________________________ Student’s Signature

Date: ______________________________ Parent/Guardian’s Signature

Note: Information obtained by this form shall not be transferred to any other person or agency than that

listed above without the written consent of the person whose signature appears hereon. If records cannot

be sent for any reason, please indicate why:__________________________________________________

_____________

I/We have attached a copy of the student’s most resent high school transcript

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Applicant Questionnaire Upward Bound –Empowerment or Upward Bound- Wichita Prep ●Wichita State University

Student’s Name ___________________________

Please answer each question:

1. What type of education do you plan to pursue after high school?

Four-year college Armed Forces Vocational Training

Two-year college Training School

2. List post-secondary institutions you are interested in attending:

3. List careers that interest you:

4. What are your career goals and how do you plan to reach them?

5. List clubs, sports and organizations you belong to at school, church, or in the community:

6. List special awards/recognition you have received:

7. Why is education important to you?

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Applicant Essay Upward Bound –Empowerment or Upward Bound- Wichita Prep ●Wichita State University

Student’s Name ___________________________

Essay (at least 75 words ) "Why I Want to Be in Upward Bound"

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

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Nomination/Recommendation Form Upward Bound –Empowerment or Upward Bound- Wichita Prep ●Wichita State University

To be completed by a principal, teacher, or counselor Student's Name: School:

Address: Age: Grade:

Counselor: GPA: Class Rank: /

Nominator: Position: Phone:

Why is this student a good candidate to participate in the Upward Bound/Wichita Prep Program?

Does the student participate in any of the following services at school? If yes, please mark the

appropriate box.

Math lab Reading/Writing Lab ESOL Program Tutoring AVID Other__________

What type of education does the student plan to pursue after high school?

Four-year college Armed Forces Vocational-Technical

Two-year college None

Does the student have a good attendance record? Yes No

Rate the student’s attitude towards education poor-1 2 3 4 5 6 7 8 9 10-excelent

Rate the student’s class room behavior poor-1 2 3 4 5 6 7 8 9 10-excelent

Without regard to student’s grades, does the student have a good work ethic? Yes No

What are the student's career interests?

What are the needs of this student in order to achieve their academic goals?

______________________________________________________________________________

______________________________________________________________________________

Additional Comments:

Signature of Nominator Date

Upward Bound Empowerment or Upward Bound Wichita Prep Programs●

Wichita State University ●1845 Fairmount Wichita, Kansas 67260-100 or 67260-0094

UBWP Phone (316) 978-3019● UBE Phone (316) 978-5343 FAX (316) 978-3403

Wichita.edu/ube ● wichita.edu/ubwp

The Upward Bound Wichita Prep program is 100% funded by the US Department of Education for 2019-2020 at $467,798. The Upward Bound Empowerment program is 100% funded by the US Department of Education for 2019-2020 at $287,536